Free Form 7 Notice of Inactivation - Colorado

FORM 7 - N OTICE OF

I NACTIVATION

To be Filed in Compliance with Rule 7 of the AMENDED RULES GOVERNING THE MEASUREMENT OF TRIBUTARY GROUND WATER DIVERSIONS LOCATED IN THE ARKANSAS RIVER BASIN to notify the DIVISION ENGINEER of intent to INACTIVATE a WELL/PUMP. SUBMIT TO: DIVISION OF WATER RESOURCES, DIVISION 2 310 E. ABRIENDO, SUITE B PUEBLO, CO 81004 TELEPHONE: FAX: INACTIVE DATE: 719.542.3368 719.544.0800

STRUCTURE ID NUMBER:

PROVIDE THE FOLLOWING ­ WHETHER OR NOT A STRUCTURE ID HAS BEEN ASSIGNED ­ USING INFORMATION SHOWN ON THE BRASS TAG FOR THE STRUCTURE. IF THERE IS NO KNOWN PERMIT OR DECREE, PLEASE NOTE AS "NA" Well Permit No.: Case or Decree No.:

CONTACT INFORMATION:
OWNER Name: Address: City, State, Zip: Phone: T H I S N O T I C E I S F O R : CHECK ONE OF THE FOLLOWING AND L IST M ETERS ENTIRE WELL (ALL PUMPS/METERS) [LIST ALL METERS]
THAT WILL

USER (IF NOT SAME AS OWNER)

NOT

BE

A CTIVE

ONLY PUMPS/METERS AS LISTED

WELL DISCONNECTED FROM POWER - YOU MUST CHECK ONE ­ AND ONLY ONE ­ OF THE FOLLOWING:
..... The WELL has no pump, OR ..... The PUMP is electrically powered, BUT there is no ELECTRIC METER, OR ..... The pump is electrically powered, BUT ELECTRIC POWER has been disconnected, OR ..... None of the above. IF THIS BOX IS CHECKED, DO NOT SIGN BELOW ... SEE BACK OF FORM

WELL OWNER/USER CERTIFICATION FOR WELL DISCONNECTED FROM POWER: ORDER OF THE DIVISION ENGINEER: By my signature on this form, I acknowledge and agree that I am hereby ordered by the DIVISION ENGINEER pursuant to section 37-92-502, CRS, that no water shall be diverted from this WELL/PUMP until such time as it has a MEASUREMENT METHOD meeting the standards of the AMENDED RULES GOVERNING THE MEASUREMENT OF TRIBUTARY GROUND WATER DIVERSIONS LOCATED IN THE ARKANSAS BASIN ("MEASUREMENT RULEs"). I agree that, should I re-activate this WELL/PUMP, I will submit to the DIVISION ENGINEER proof of a valid MEASUREMENT METHOD on FORM 3.1 or 3.2 OR provide NOTICE OF RE-ACTIVATION on FORM 7.1 if proof of a valid MEASUREMENT METHOD is already on file with the DIVISION ENGINEER. I acknowledge that should I reactivate this WELL/PUMP without submitting the necessary information to the DIVISION ENGINEER, I will be in violation of the MEASUREMENT RULES and in violation of this ORDER of the DIVISION ENGINEER, and may be subject to a complaint in the WATER COURT, fines of up to $500 per day, court costs and attorney fees as provided in 37-92-503, CRS.
I hereby verify that the WELL/PUMP as described above is inactive and disconnected from any and all power sources and will not be used until such time as I notify the Division Engineer in writing of my intent to re-activate this WELL/PUMP by filing a FORM 7.1, NOTICE OF WELL RE-ACTIVATION. I have read and understand the above ORDER OF THE DIVISION ENGINEER. I understand that should I desire to re-activate the above described WELL/PUMP that all aspects of the above captioned rules are in full force and effect. This FORM in and of itself offers no proof or disproof of abandonment of the WATER RIGHT(S), if any, associated with this WELL/PUMP.

SIGNATURE:
CHECK ONE:
FORM 70 041108

DATE:
WELL OWNER WELL USER
PAGE 1 OF 3
04/11/08

FORM 7 - NOTICE

OF

INACTIVATION

04/01/08

**Complete this side ONLY if you checked the last box on the first page**
A variance request MUST be renewed annually. Approval is subject to a Field Inspection of the well.

TYPE OF VARIANCE REQUESTED: You must check ONLY ONE box AND answer every question for that box. .. There is POWER at the ELECTRIC METER, but the Pump is the only ELECTRICAL DEVICE on the ELECTRIC METER: Provide the following information: Name of Power Company: Power Company Account No.: Power Company Meter No.:
From Power Co. Bill On Power Meter

... There is POWER at the ELECTRIC METER, but the Pump is NOT the only ELECTRICAL DEVICE on the ELECTRIC METER: The PUMP must be disabled such that it cannot be used. Describe how the PUMP is disabled:

Provide the following information: Power Company Account No.: Power Company Meter No.:

Name of Power Company:
From Power Co. Bill On Power Meter

... Pump is not electrically powered (e.g., it is powered by solar energy, propane, gasoline, etc. or is artesian): The pump must be in some way disabled such that it cannot be used. Describe how the pump is disabled:

VARIANCE REQUEST FOR A WELL THAT REMAINS CONNECTED TO POWER WELL OWNER/USER CERTIFICATION:
ORDER OF THE DIVISION ENGINEER: By my signature on this form, I acknowledge and agree that I am hereby ordered by the DIVISION ENGINEER pursuant to section 37-92-502, CRS, that no WATER shall be diverted from this WELL until such time as it has a MEASUREMENT METHOD meeting the standards of the AMENDED RULES GOVERNING THE MEASUREMENT OF TRIBUTARY GROUND WATER DIVERSIONS LOCATED IN THE ARKANSAS BASIN (AMENDED MEASUREMENT RULEs). I agree that should prior to re-activating or using this WELL, I will submit to the DIVISION ENGINEER proof of a VALID MEASUREMENT METHOD on FORM 3.1 or 3.2 OR provide NOTICE OF RE-ACTIVATION on FORM 7.1 if proof of a VALID MEASUREMENT METHOD is already on file with the DIVISION ENGINEER. I acknowledge that should I reactivate this WELL without submitting the necessary information to the DIVISION ENGINEER, I will be in violation of the AMENDED MEASUREMENT RULEs and in violation of this ORDER OF THE DIVISION ENGINEER, and may be subject to a COMPLAINT in WATER COURT, fines of up to $500 per day, court costs and attorney fees as provided in § 37-92-503, CRS. I hereby verify that WATER will not be diverted from the above-described WELL. Pursuant to RULE 11
of the AMENDED MEASUREMENT RULEs, I request a VARIANCE from the requirement to disconnect the WELL from the POWER SOURCE. I understand that as a CONDITION OF APPROVAL of this VARIANCE REQUEST, I must file a NOTICE OF INACTIVATION each year or bring the WELL into compliance with the AMENDED MEASUREMENT RULEs.

I have read and understand the above ORDER OF THE DIVISION ENGINEER. I understand that should I
desire to re-activate the above described WELL, that all aspects of the AMENDED MEASUREMENT RULEs will be in full force and effect. Completion and submittal of this FORM in has no bearing on potential abandonment of WATER RIGHT(S) associated with this WELL.

SIGNATURE:
CHECK ONE:
INSPECTED BY: DATE:

DATE:
WELL OWNER
APPROVED:

WELL USER
YES . NO... FIELD COMMENTS:

FOR DWR USE ONLY

FORM 70 041108

PAGE 2 OF 3

04/11/08

FORM 7 - N O T I C E O F I N A C T I V E W E L L

FORM 70 041108

PAGE 2 OF 3

04/11/08